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BASICS

Description

  • Recurrent headaches lasting 4–72 hours
  • Typically unilateral, pulsating, moderate to severe intensity
  • Associated nausea, photophobia, phonophobia
  • Subtypes:
  • Without aura (>80%)
  • With aura (visual, motor, sensory, brainstem symptoms; reversible; last up to 60 mins)
  • Chronic migraine (>15 days/month for ≥3 months)
  • Menstrual migraine (attacks near menstruation)
  • Menstrually related migraine (plus attacks at other times)
  • Rare subtypes:
  • Status migrainosus (>72 hours)
  • Prolonged aura (>60 minutes; consider secondary causes)
  • Ocular migraine
  • Vertiginous migraine
  • Acephalgic migraine (aura without headache)

Epidemiology

  • Female to male ratio 3:1
  • Affects >28 million Americans

Etiology and Pathophysiology

  • Trigeminovascular system activation releases neuropeptides (substance P, CGRP) causing vasodilation and neurogenic inflammation
  • Cortical spreading depression explains aura phenomenon

  • 80% have positive family history

Risk Factors

  • Female sex (menstrual cycle influence)
  • Positive family history
  • Common triggers:
  • Sleep disruption
  • Diet: skipped meals (48%), alcohol (32%), chocolate (20%), cheese (13%), caffeine overuse (14%), MSG (12%), artificial sweeteners
  • Medications: estrogens, vasodilators

General Prevention

  • Lifestyle modification: good sleep hygiene, stress management, healthy diet, hydration, exercise
  • Prophylactic medications for frequent attacks

Commonly Associated Conditions

  • Depression, anxiety, PTSD
  • Sleep disturbances (e.g., sleep apnea)
  • Cerebral vascular disease
  • Seizure disorders
  • Irritable bowel syndrome
  • Other pain syndromes (cervical spine disease, endometriosis)

DIAGNOSIS

History

  • Use ID migraine screening tool: nausea, photophobia, disability
  • Headache characteristics:
  • Usually unilateral (30-40% bilateral)
  • Throbbing pain (40% nonthrobbing)
  • Duration 4–72 hours
  • Aggravated by movement; associated nausea, vomiting, photophobia, phonophobia, vertigo
  • May be preceded by aura (visual disruptions, somatosensory changes, speech difficulties)
  • Maintain headache diary (frequency, medication use, triggers)
  • Use Migraine Disability Assessment (MiDAS) for disability evaluation

Physical Exam

  • Neurologic exam including funduscopy to exclude other causes:
  • Gait abnormalities
  • Motor deficits
  • Altered mental status
  • Papilledema

Differential Diagnosis

  • Other primary headache syndromes: IIH, trigeminal autonomic cephalgias (TACs)
  • Secondary headaches: medication overuse, tumor, infection, vascular disorders

Diagnostic Tests

  • Neuroimaging (MRI/CT) if red flags or abnormal exam
  • Red flags include:
  • New onset >50 years
  • Change in headache pattern
  • Progressive neurologic symptoms
  • Prolonged/different aura
  • Head CT if concern for hemorrhage
  • EEG not routinely indicated unless altered consciousness or seizures
  • Assess systemic disease if indicated (thyroid, SLE, vitamin deficiencies)

Pediatric Considerations

  • NSAIDs first-line for acute treatment
  • Rizatriptan approved for age >6 years
  • Other triptans (sumatriptan, almotriptan, zolmitriptan) approved for age >12 years

Pregnancy Considerations

  • Frequency may decrease in 2nd and 3rd trimesters
  • New headaches in pregnancy require evaluation for preeclampsia, venous sinus thrombosis
  • No migraine drugs FDA approved; acetaminophen, antiemetics, short-acting opioids considered
  • Triptans appear safe if compelling need
  • Ergotamines contraindicated
  • Avoid herbal remedies
  • Beta-blockers and calcium channel blockers effective for prophylaxis
  • Occipital nerve blocks and trigger point injections safe

TREATMENT (Summary in Part 2)

References

  1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.
  2. Lipton RB, Bigal ME, et al. Validation of ID Migraine as a brief screening tool. Neurology. 2003.
  3. Sacco S, Merki-Feld GS, Ægidius KL, et al. Hormonal contraceptives and risk of ischemic stroke in women with migraine: consensus statement. J Headache Pain. 2017;18(1):108.
  4. Patterson-Gentile C, Szperka CL. Pediatric migraine therapy review. JAMA Neurol. 2018;75(7):881-887.